Radical ideas to revolutionise a broken NHS. Your thoughts?

[DelayRepay]

I published a variation of the following some 2 years ago in another thread on the politicisation of the NHS - I have not updated the numbers but they are not far off. It gives an outline of the German Health Insurance system. I would suggest that as the German health insurance system is the oldest in Europe and still works Britain could well learn from it. There are parallel insurance systems for unemployment, pensions, social care and so on and many people have a private 'Third Party' insurance as the health insurance is not an accident insurance if, for example, your dog bites a passer-by and he/she needs attention at A&E. You are expected to pay the A&E costs.

Firstly a bit of history. In the Middle Ages the craft guilds provided an early form of social insurance: guild members paid into a fund which was then used to help individuals if they got into financial difficulties because of, e.g., an illness. From the beginning of the industrial revolution local insurance funds were organised for industrial workers, a bit like the GWR's health insurance scheme. All these different insurances were then standardised by Otto von Bismarck in the late nineteenth century, the first being health insurance for factory workers in the event of illness in 1883. It rather predates the NHS...

Anyone who was insured was granted the right to free medical treatment and medicine, as well as sickness benefits and a funeral allowance. At that time, about 10% of the population was insured – over the years statutory health insurance was extended to other groups of workers. One of the last to be included were farmers in the early 1950s and seasonal workers in the early 1970s - my late father-in-law, a GP with a practice which was predominantly in the countryside, was often paid in kind which made life difficult for my mother-in-law as at any one time in the year all the farmers paid in kind with the same produce! Apparently nearly 100% of the population is covered by insurance now; there seems to be about 0.1% to 0.3% (depending on the data source) who are not covered but I cannot find out which group of people that includes.

The introduction of health insurance was followed by the introduction of statutory accident insurance (1884) and pension funds (1889). Unemployment insurance was introduced in 1927.

Health insurance is compulsory: everyone must have statutory health insurance (called “gesetzliche Krankenversicherung” – GKV) as soon as a work contract is signed provided that their gross earnings are under a fixed limit (“Versicherungspflichtgrenze“), in 2017 (the latest date for which I have quickly found the numbers) this was €4,800 a month. This covers primary care with registered doctors, hospital care (both in- and out-patient) and basic dental treatment. Non-working dependents living at the same address and registered with the Krankenkasse are covered at no extra cost. It does not cover consultations with private doctors, private rooms in hospitals, alternative or complementary treatments, dental implants or spectacles or contact lenses for adults.

There is a lower limit of income for contributions, people earning less than about €850 per month have their contributions paid by the state.

The insurance is run by the Krankenkassen, non-profit making associations which must all charge the same basic rate of 14.6% of the individual’s eligible gross salary, up to a maximum of, in 2017, €4,350 a month. The premium is shared equally between the employee and the employer. Even if one’s income is higher than the Versicherungspflichtgrenze this is the upper limit to the premiums. Once signed up with one of the Krankenkassen one has to stay with it for (IIRC) 18 months or 2 years after which time one can change to another. There are over 100, many tuned to the needs of certain types of employment or social situation.

No cash changes hand if one visits a doctor or goes to hospital - health care is free at the point of use. The user experience is exactly the same as here except that waiting times are in general shorter and the buildings less shabby.

Some parts of medical insurance premiums are tax-deductible.

The health system is self-governing - the Federal Government plays no part in the operational details of the health system although it sets the framework for medical care such as benefits; eligibility; compulsory membership; the physical, emotional, mental, curative, and preventive risks to be covered; income maintenance during temporary illness; the split between employer and employee contributions to the statutory insurance; and other central issues. Below this level health and social care generally is a matter devolved to the individual Länder and each Land makes its own arrangements.

This is not to say that there are not problems - one of the biggest ones at the moment is the shortage of personnel leading to all sorts of delays, but this is generally localised. I'm in Berlin at the moment and local difficulties here cover a large area...

Interesting - so who actually employs the doctors and runs the hospitals? Is it the state, are they run by the Krankenkassen, or are they private?

And out of interest what happens in an emergency? I assume if you find someone collapsed in the street, you can still call an ambulance and they'll get immediate care without any worries about whether they have insurance? Even if they are one of the 0.1% without cover?

 

[dm1]

I imagine for emergency stuff it's treat first, ask questions about billing later. Most of the billing occurs after treatment in any case.

 

[geoffk]

No-one has yet suggested that perhaps the NHS should stop doing certain procedures. Cosmetic surgery is not routinely offered by the NHS but may be provided for psychological or other health reasons, and presumably for military personnel injured on active service. We would probably agree with this approach but what other treatments might be reviewed?

 

[Adrian1980uk]

The key for me is moving the budget for social care should come under the hospitals trust budget, that way the choice is there's, pay £1000 a night in hospital out of the budget or £500 for care home or set it up so once a patient is ready for discharge, the cost of hospital is charged out to the local council and a similar process for ambulance trusts transferring to a&e, for time over 30, the cost of staffing the ambulance is invoiced to the hospital. Will focus the mind, a part from bad press, the current situation of bed blocking actually saves money from the councils social care budget, what's the incentive to do anything about it

 

[Bletchleyite]

Interesting - so who actually employs the doctors and runs the hospitals? Is it the state, are they run by the Krankenkassen, or are they private?

It varies, though I believe hospitals are mostly things like charities, or sometimes run by local authorities. And like here, individual practices are for-profit businesses. It's quite common that a specialist will have their own premises rather than them all being concentrated in a hospital like here, if you walk round a typical German town you'll often see plaques on the doors of buildings saying stuff like Dr.med. Max Mustermann*, Hausarzt or something.

* The German equivalent of "A N Other", literally "Max Example Man"

 

[Fyldeboy]

I think medical students (nurses/doctors etc) should pay for their tuition via student loans, but:

• After X years qualified working in the NHS, their student loan is wiped; and
• Time spent 'in training' but actually providing NHS care should be paid at an appropriate rate

Pro-rata, there are less managers in the NHS than in private business, maybe they need more!!!! Certainly, from a recent long stay in a 750 bed hospital, I got the impression that the NHS was too big to be managed, but if they had enough managers, and probably a revised management structure, maybe it could be done.

 

[coppercapped]

To address some of the issues about emergency care, organisation of the hospitals in Germany and a correction.

Starting with the correction - the Krankenkassen are 'not for dividend', not 'not for profit' organisations as I originally wrote. This means that they can cover sudden surges in demand - such as occurred at the beginning of the Covid pandemic - out of retained profits without collapsing under the stress.

The most important point about the German healthcare system is that the right to health care is regarded as sacrosanct and is guaranteed by the (written) Constitution. Universality of coverage, comprehensive benefits, the principle of the healthy paying for the sick, and a redistributive element in the financing of health care have all been endorsed by all political parties and are fixed in the country's Constitution.

The responsibility for administering and providing health care is delegated to non-state entities, including national and regional associations of health care providers, Land hospital associations, nonprofit insurance funds, private insurance companies, and some voluntary organisations.

The Länder own and partially finance medical school and accredited teaching hospitals. The Länder also enforce accreditation and licensing of health facilities and of health professionals working in social services and are also responsible for policy development and implementation of social and nursing services, social assistance, youth services, and social work.

One of the commonest criticisms of insurance based health care is its inequality. This is most certainly not true in Germany. The premiums paid are not determined in any way by age, sex, ethnic grouping or existing conditions - they are a fixed proportion of income. Portability of coverage from town to town or Land to Land, eligibility, and benefits are independent of any regional or local re-interpretations by either insurers, politicians, administrators, or health care providers. Universal coverage is honoured by any surgery or hospital. No one in need of care can be turned away without running a risk of violating the code of medical ethics or Land hospital laws.

 

[matacaster]

As in have a sit-and-wait GP service at hospitals? That's actually a pretty good idea.

It might make more sense for GP practices to cease having a GP! The practice would be run by an upskilled senior nurse. They can Google the mayo clinic or similar just like GPs. GPs would be moved to take clinics at hospitals as a first stage before A&E.
GP function is questionable.
It's often difficult to see them
Some patients get well before they can get an appointment
If they THINK it's serious they send you to a&e
They spend 10 mins chatting to OAPs
They prescribe pills like smarties including things like paracetamol which can be had for peanuts at supermarket but cost NHS a lot
Drs sometimes moonlight doing on-call overnight
They were so overworked during the pandemic that they couldn't go on .... Until the govt gave them a huge bung!
They cost several hundreds of thousands to train and promptly work part time (thanks to Blair) or emigrate for even more wonga. Blair also made their pensions so lucrative that they are able to retire and lead a life of luxury way before their patients.
Wouldnt a well trained nurse practitioner who you could actually see promptly be better than a GP, many of whom appear to not like seeing their patients at all?

Their function appears to be one of acting as a gatekeeper to avoid people with minor issues seeing a specialist. They don't generally do any treatment now as far as I am aware and ask for blood tests for most conditions to avoid any misdiagnosis claims.

 

[david1212]

Several interesting options and opinions here.

Overall while I would support a NHS A&E intoxication charge in reality I do not think the administration to introduce and operate be worthwhile. While unpleasant for staff to deal with even without bad behaviour and even physical abuse plus a bed occupied for a while until the person can be discharged to nurse their hangover, cut and bruises at home on a relative scale is the cost high?

I guess there is a much higher cost dealing directly and indirectly with long term alcoholism, drug (ab)use, smoking and obesity.

Generally I do not support a charge for sports injuries. The exception would be high risk sports e.g. skiing and recreation e.g. hang gliding, rock climbing but in reality again would the administration to introduce and operate be worthwhile.

I support legal euthanasia, see my post here, but only ever by choice not enforced. Directly it would create capacity in care homes, nursing homes and hospices so more beds in hospitals for those who need to be there.

The whole system of discharge, after care at home and long term residential care needs sorting out. It was a mess 25+ years ago and still is now. Where a return to home requires equipment first the need should be passed from the hospital to the provision promptly then delivery planned promptly, if necessary as no prior access synchronised with the arrival of the hospital transport carrying the patient. For transfer to residential care the hospital bed should not be blocked while the funding package between national social security, local social security and patient contribution is finalised.

For training rather than upfront funding instead of student loans for certain courses once the person has qualified and is employed by the NHS in addition to the salary the student loan annual repayments are made. This way the state does not loose out if the student does not successfully complete the course nor choose not to work for the NHS.

Ensuring that A&E is not being used in place of GP surgeries and walk-in centres. Back 20 or so years ago the out-of-hours GP surgery was at the hospital but totally separate from A&E.

 

[class68fan]

Generally GPs and consultants are heavily overbooked, so the odd missed appointment helps them catch up or get a break for a cup of tea or to use the loo. It's not the issue some claim it to be.

dont be silly every missed appointment is a missed oportunity for another person to have had an appointment. then another slot is taken for them holding back yet another person

 

[Bletchleyite]

dont be silly every missed appointment is a missed oportunity for another person to have had an appointment. then another slot is taken for them holding back yet another person

It's not. GPs overbook quite spectacularly, most are running half an hour late by the end of the day. It's very easy to do that because you know your percentage of no-shows, and in the unlikely event of everyone showing you just run late by the end of the day.

I think not cancelling is rude and I would always cancel, but it isn't a problem and doesn't in fact prevent anyone seeing a doctor, because if everyone always showed up they'd offer fewer appointments. What does that is the chronic undercapacity.

You could charge for missed appointments, but it's a bit disingenuous to think that would be anything more than an opportunity to raise revenue.

 

[duncanp]

When I played rugby, part of my membership fee at the rugby club went towards an insurance scheme run by the RFU which paid for private medical insurance that could be used if you were seriously injured during the course of a game.

I think all organised sports should consider something similar, as this would help to reduce some of the load on the NHS, and would mean that people got seen more quickly.

Whilst I am not against euthanasia in principle, my fear is that the NHS would use the law to in effect withdraw treatment from those over a certain age, or where the condition was too complex or expensive to treat.

Instead they would put pressure on people to consider euthanasia, simply as a means to cut costs.

 

[Bletchleyite]

I think all organised sports should consider something similar, as this would help to reduce some of the load on the NHS, and would mean that people got seen more quickly.

I very, very, very, very strongly don't. Sport is to be encouraged. Under no circumstances should barriers of any kind be placed in the way of sport.

If you want to reduce dependency on the NHS by doing something to sport, subsidise it and get more people taking part, and they'll be healthier and less obese.

That even extends to stuff like climbing (which is nowhere near as dangerous as people make out; climbing single-pitch on top-rope you're more likely to get hurt driving to the crag or wall), which while it doesn't do much for your aerobic fitness it does tend to mean people choose to eat better if they enjoy it, as climbing when you're fat is a heck of a lot of effort.

 

[duncanp]

I very, very, very, very strongly don't. Sport is to be encouraged. Under no circumstances should barriers of any kind be placed in the way of sport.

If you want to reduce dependency on the NHS by doing something to sport, subsidise it and get more people taking part, and they'll be healthier and less obese.

That even extends to stuff like climbing (which is nowhere near as dangerous as people make out; climbing single-pitch on top-rope you're more likely to get hurt driving to the crag or wall), which while it doesn't do much for your aerobic fitness it does tend to mean people choose to eat better if they enjoy it, as climbing when you're fat is a heck of a lot of effort.

I meant this to apply to organised team sports such as football, rugby or cricket, where you join a club and have to pay a subscription to the club in order to use the facilities and play in a game. You would have to pay to play these sports anyway, and the additional costs of the insurance would be very little.


I did not mean this to apply to sports practised individually such as climbing or hill walking, or where you play 5 a side football at the local sports centre.

 

[njamescouk]

just fund it properly, the last thing the NHS needs is more managers mucking about "revolutionising" things.

 

[Bletchleyite]

I meant this to apply to organised team sports such as football, rugby or cricket, where you join a club and have to pay a subscription to the club in order to use the facilities and play in a game. You would have to pay to play these sports anyway, and the additional costs of the insurance would be very little.

Again absolutely not. Sport should be encouraged in all its forms. Taxing it additionally in any form is unacceptable - arguably it should be subsidised, not taxed.

If you want to tax anything more to reduce dependency on the NHS, it's motoring, alcohol, tobacco and unhealthy foods. Obesity and associated stuff like high blood pressure is a far, far higher demand on the NHS than sporting injuries.

 

[Mogster]

I would not support any plan to charge for access to GPs or A&E, even if the person's injury is self inflicted, or they are deemed a time waster, and/or the charge is only a nominal £10. I think any charges would put some people with genuine illnesses off seeking help, which could result in treatable conditions becoming fatal and/or costing far more to treat further down the line.

I would however like to see greater use of 'walk in' type services where you can be triaged by a professional such as a nurse or pharmacist (depending on your condition) who can refer you to a GP if necessary, or provide advice or prescriptions, or referral to another service where that's more appropriate. This could also be by telephone or video call for certain conditions where it suited the patient.

I really think charging to see the doctor (as happens with the dentist or optician) is worth exploring. Apparently countries where healthcare is free at the point of use, Japan is an example iirc, have 4x the number of people presenting than systems that implement even a nominal charge. Free at the point of use systems tend to be the ones with the worst capacity issues. The thing is, you’d imagine outcomes would be affected, but it seems not, it seems the charge makes no difference. People still go to see the doctor, just when they need to rather than on a whim.

 

[Bletchleyite]

People still go to see the doctor, just when they need to rather than on a whim.

Who goes to the doctor for a laugh? People go because they are concerned about their health.

Some people are hypochondriacs, sure, but they'll just become slightly poorer hypochondriacs.

If there are e.g. lonely older people who go because they need a chat, then you've got a mental health problem there you need to actually solve (my local surgery does organised short local walks, which is one thing that can help against loneliness in older people).

 

[tomuk]

Again absolutely not. Sport should be encouraged in all its forms. Taxing it additionally in any form is unacceptable - arguably it should be subsidised, not taxed.

If you want to tax anything more to reduce dependency on the NHS, it's motoring, alcohol, tobacco and unhealthy foods. Obesity and associated stuff like high blood pressure is a far, far higher demand on the NHS than sporting injuries.

I'm sorry but taking part in sports does increase your risk of injury and I therefore see no problem with a requirement for you to take out insurance. As duncamp suggested this would apply to organised activiies above a normal day to day level of exercise.

 

[Domh245]

Again absolutely not. Sport should be encouraged in all its forms. Taxing it additionally in any form is unacceptable - arguably it should be subsidised, not taxed.

Sport should be encouraged, but I think you could definitely make an argument for (slightly) discouraging activities where the risk of severe injury is higher. For example, Athletics would seem preferable to Rugby, as one is (typically) mostly running whilst the other involves running & making physical contact with other participants with significantly higher likelihood of injury!

Cricket is probably a lower risk sport on the grand scale of things - particularly with the protection worn which reduces the risk from ball injuries, with football falling somewhere between

 

[Bletchleyite]

Sport should be encouraged, but I think you could definitely make an argument for (slightly) discouraging activities where the risk of severe injury is higher. For example, Athletics would seem preferable to Rugby, as one is (typically) mostly running whilst the other involves running & making physical contact with other participants with significantly higher likelihood of injury!

Cricket is probably a lower risk sport on the grand scale of things - particularly with the protection worn which reduces the risk from ball injuries, with football falling somewhere between

That is a dangerous slippery slope and not one we should go down. On balance, partaking of sport, even the more dangerous ones, reduces the load on the NHS. As I said, for example climbers generally keep themselves a healthy weight and eat well as if you're fat it's a heck of an effort, for example.

Under no circumstances should any form of sport or physical activity not be covered by the NHS.

 

[DynamicSpirit]

just fund it properly, the last thing the NHS needs is more managers mucking about "revolutionising" things.

The problem with saying 'just fund it properly' is twofold: Firstly, most of us have an almost infinite desire for better health and longer lives, and as technology improves and more and more things become treatable, demand for treatment just grows and grows. By shoving in more money (which remember, will have to be paid for by higher taxes) you might be able to stave off the crisis for a few years. But what are you going to do in 10 year's time when another raft of technology improvements mean we're all demanding even better NHS treatment again? You can't just keep raising taxes indefinitely to fund our ever-growing demand for healthcare. At some point, you have to have a serious discussion about what things should and shouldn't be provided for free at point of use, paid for by the taxpayer.

Secondly, even if it wasn't for the issue of potentially infinite demand for healthcare, throwing more money into something is almost never a good idea if you don't have a clear idea of precisely how that money is supposed to be spent, and what you expect that organisation to deliver with the money. Without those plans, extra money has an extraordinary habit of disappearing on more managers and tick-box exercises etc. (This isn't a specific criticism of the NHS btw - the same thing applies to just about any organisation)

 

[Bletchleyite]

The problem with saying 'just fund it properly' is twofold: Firstly, most of us have an almost infinite desire for better health and longer lives, and as technology improves and more and more things become treatable, demand for treatment just grows and grows. By shoving in more money (which remember, will have to be paid for by higher taxes) you might be able to stave off the crisis for a few years. But what are you going to do in 10 year's time when another raft of technology improvements mean we're all demanding even better NHS treatment again? You can't just keep raising taxes indefinitely to fund our ever-growing demand for healthcare. At some point, you have to have a serious discussion about what things should and shouldn't be provided for free at point of use, paid for by the taxpayer.

Secondly, even if it wasn't for the issue of potentially infinite demand for healthcare, throwing more money into something is almost never a good idea if you don't have a clear idea of precisely how that money is supposed to be spent, and what you expect that organisation to deliver with the money. Without those plans, extra money has an extraordinary habit of disappearing on more managers and tick-box exercises etc. (This isn't a specific criticism of the NHS btw - the same thing applies to just about any organisation)

I think this sort of thing is very much helped by the insurance schemes in that you can have a document of insurance defining what the entitlement is, and if that needs to change there can be the appropriate national debate on it, also you know what you're funding.

 

[duncanp]

That is a dangerous slippery slope and not one we should go down. On balance, partaking of sport, even the more dangerous ones, reduces the load on the NHS. As I said, for example climbers generally keep themselves a healthy weight and eat well as if you're fat it's a heck of an effort, for example.

Under no circumstances should any form of sport or physical activity not be covered by the NHS.

The insurance scheme I mentioned when playing rugby didn't preclude you from getting treatment under the NHS.

If you were injured during a game you would go to the local A&E just as you would for an injury which occurred anywhere else.

However, if the assessment at A&E showed that you needed treatment long term, or surgery, you could then opt to claim on the insurance, which would generally be quicker than waiting for the NHS.

The insurance also covered people who received life changing injuries, such as a broken neck, during a game, an who would need assistance long after the immediate medical treatment had finished.

 

[Bletchleyite]

The insurance scheme I mentioned when playing rugby didn't preclude you from getting treatment under the NHS.

If you were injured during a game you would go to the local A&E just as you would for an injury which occurred anywhere else.

However, if the assessment at A&E showed that you needed treatment long term, or surgery, you could then opt to claim on the insurance, which would generally be quicker than waiting for the NHS.

The insurance also covered people who received life changing injuries, such as a broken neck, during a game, an who would need assistance long after the immediate medical treatment had finished.

Those who wish to take private insurance for these matters presently can.

I remain as strongly as is humanly possible opposed to any form of compulsory medical insurance for any form of sport or physical activity. In a country with an obesity crisis which IS heavily loading the NHS, ALL sport is to be massively encouraged. The number of rugby players who end up in a wheelchair is tiny compared to the number of fat people who don't do sport who are having heart attacks, strokes etc.

 

[tomuk]

Those who wish to take private insurance for these matters presently can.

I remain as strongly as is humanly possible opposed to any form of compulsory medical insurance for any form of sport or physical activity. In a country with an obesity crisis which IS heavily loading the NHS, ALL sport is to be massively encouraged. The number of rugby players who end up in a wheelchair is tiny compared to the number of fat people who don't do sport who are having heart attacks, strokes etc.

The obesity 'crisis' won't be fixed by everyone playing rugby or snow boarding or other high risk sport. There are sports which over and above any general health benefit are riskier and more likely to produce injuries. It isn't just about catastrophic injuries either for example what about a guy who in his twenties does his knee in playing rugby, he gets patched up by NHS then in his forties the injury catches up with him and hinders him working as a self employed plumber. It starts out with painkillers and visits to a physio but ends up with a first knee replacement and ongoing reduced capability. Is he not as much of a burden as some obese people?

 

[Mogster]

Who goes to the doctor for a laugh? People go because they are concerned about their health.

Some people are hypochondriacs, sure, but they'll just become slightly poorer hypochondriacs.

If there are e.g. lonely older people who go because they need a chat, then you've got a mental health problem there you need to actually solve (my local surgery does organised short local walks, which is one thing that can help against loneliness in older people).

Maybe they aren’t attending “for a laugh” but a significant number have become habituated to GP attendance. Frequently these visits are to discuss problems that could and should be self managed, coughs/colds strains/sprains. “Free” at the point of care fuels these visits where a nominal charge would at least mean they were given a second thought. These visits take £BNs a year out of NHS resources.

As an NHS employee I dislike the whole “NHS is FREE” concept, it leads to the NHS being viewed as some sort of charity organisation. The NHS isn’t free, it isn’t some sort of charity, we pay for it handsomely in our taxes.

 

[Ediswan]

I remain as strongly as is humanly possible opposed to any form of compulsory medical insurance for any form of sport or physical activity. In a country with an obesity crisis which IS heavily loading the NHS, ALL sport is to be massively encouraged.

Agreed. Currently, the UK is very good at not charging. Unlike a lot of countries, the UK does not charge for search and rescue. Even helicopter rescue is free.

 

[duncanp]

Maybe they aren’t attending “for a laugh” but a significant number have become habituated to GP attendance. Frequently these visits are to discuss problems that could and should be self managed, coughs/colds strains/sprains. “Free” at the point of care fuels these visits where a nominal charge would at least mean they were given a second thought. These visits take £BNs a year out of NHS resources.

As an NHS employee I dislike the whole “NHS is FREE” concept, it leads to the NHS being viewed as some sort of charity organisation. The NHS isn’t free, it isn’t some sort of charity, we pay for it handsomely in our taxes.

If we are ever going to solve the current problems in the NHS we somehow have to suppress demand for its services.

By this I mean that people should self manage things such as coughs, colds and sprains, and seek medical advice from a pharmacist or NHS111 before taking the matter further.

Similarly for A&E, people should think twice before going there with conditions that are not emergencies, and A&E departments should have a triage nurse that turns people away if they arrive with a condition that should really be treated elsewhere.

For example, I once saw someone arrive at an A&E department after being stung by a bee. The only circumstances in which you would need to go to A&E after a bee sting is if you are suffering a severe allergic reaction which is affecting your ability to breathe.

It was noticeable during the early stages of the COVID pandemic that A&E attendances dropped quite significantly, which just goes to prove that many A&E attendances are not really emergencies, and could (and should) be dealt with elsewhere.

If the NHS is strict about turning away inappropriate A&E attendances, people will get the message and will seek treatment via a more appropriate route.

 

[Bletchleyite]

As an NHS employee I dislike the whole “NHS is FREE” concept, it leads to the NHS being viewed as some sort of charity organisation. The NHS isn’t free, it isn’t some sort of charity, we pay for it handsomely in our taxes.

That's another reason I advocate a social insurance scheme. People would see it as a separate line on their payslip and so would see what they were paying specifically for healthcare. This might lead to it being valued more, and equally to a culture that they are a consumer (a bit like students are now) and shouldn't accept when it's a bit rubbish.

Even if left as it is I would advocate, for this reason, separating the NHS component out from income tax. (No, NI doesn't pay for it, that's for other stuff like pensions). And I think I'd even separate it out for people receiving benefits on whatever statement they get regarding that, even if it means artificially inflating the benefit figure to "pay for" it.

== Doublepost prevention - post automatically merged: 7 Jan 2023 ==

It was noticeable during the early stages of the COVID pandemic that A&E attendances dropped quite significantly, which just goes to prove that many A&E attendances are not really emergencies, and could (and should) be dealt with elsewhere.

Wow, just wow.

You are aware that there's been a huge growth in undiagnosed conditions because of people staying away from the NHS during COVID, right? And that those conditions are getting serious and biting people on the proverbial backside for having stayed away?

But regarding bee stings, if there are people who feel they need to sit and wait 4 hours to see someone about them because they don't know how to get them out, just have a junior nurse there who can deal with that sort of thing. (I refer back to my suggestion above that A&Es should actually be "one stop health shops" for things that people need advice about that aren't known in advance).